Family Counseling Form

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CLIENT DETAILS

CHILD'S INFORMATION

Date

Layout

Child's Name

First

Last

Sex

Date of Birth

Status

PARENT INFORMATION

Layout

Parent #1 Name

First

Last

Parent #1 Marital Status

Parent #1 Phone

Parent #1 Email

Parent #1 Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent #1 Current or Previous Occupation

Parent #1 Church Affiliation

Parent #2 Name

First

Last

Parent #2 Marital Status

Parent #2 Phone

Parent #2 Email

Parent #2 Mailing Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Parent #2 Current or Previous Occupation

Parent #2 Church Affiliation

Brief Explanation of Concerns

SIBLING INFORMATION

Layout

Sibling #1 Name

First

Last

Sibling #1 Date of Birth

Sibling #1 Status

Sibling #2 Name

First

Last

Sibling #2 Date of Birth

Sibling #2 Status

Sibling #3 Name

First

Last

Sibling #3 Date of Birth

Sibling #3 Status

FINAL STEPS

If you are divorced from the biological parent of the child(ren) you are seeking therapy for, do you have a divorce decree or legal document that states who can consent to counseling?

If you are the legal guardian of the child that counseling is being sought for, do you have legal documentation that states you can consent to therapy?

Legal Documentation Notice

*Please email prior to your session or bring a copy of your signed divorce decree/legal document regarding ability to consent to the counseling of a minor(s) to your Parent Intake session.

Family Counseling Form

CLIENT DETAILS

CHILD'S INFORMATION

PARENT INFORMATION

SIBLING INFORMATION

FINAL STEPS

Legal Documentation Notice

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